1860-1889

By 1860 all the great general hospitals had been founded and the basic structure of the metropolitan hospital system was well established. Some earlier difficulties were on the way to solution. Nepotism was far less blatant and the establishment of the General Medical Council had provided the profession with a new stability. Yet the decade of the sixties was a period of rapid political change, indeed political unrest. The debates about education and the franchise, like those about Poor Law reform, were national in character. Advances in science — the publication of The Origin of Species is often quoted — and in medical specialisation posed problems for hospitals throughout the country. Other issues were essentially metropolitan, for the rising population and the pattern of growth of London increasingly revealed the inappropriate locations of hospitals. There was no consensus about the nature, let alone the solution, of many of the difficulties; for example the basis on which patients were selected for admission, the way to finance the hospitals, or questions of governance and authority. No easy solutions were to emerge in the next thirty years, but the many interests involved and the constraints within which the hospitals worked became more clearly defined.

‘In 1745 — subsequently to the foundation of Guy’s — only a narrow strip stretching a little way above and below London Bridge was built upon. In 1818 this area was about doubled. In 1834 the area of 1818 was doubled; and in 1857 the inhabited area had doubled again. A dense population had stretched below Greenwich, as high as Battersea, and far to the south. Still, for a hundred years, no new hospital had been erected.’

The hospital accommodation for south London amounted to 1,130 beds for an area of 70 square miles and a census population of 773,000. Further, the counties of Surrey and Kent sent ‘large contingents to the crowds of sick and maimed who throng the gates of the two hospitals at the foot of London Bridge’.’ The Lancet contrasted this pressure with the services enjoyed by the more fortunate population on the north of the Thames. Here, in fifty square miles were 2,000,000 people, twelve hospitals, at least 2,656 beds and the vast majority of the special hospitals. Philanthropy had been lavish in the north with 70 beds per square mile, one for every 536 inhabitants. The south housed a larger proportion of the ‘labouring population’ and had 16 beds per square mile, one bed to every 700 inhabitants.

The buildings of the old St Thomas’s Hospital in Southwark had been known to be substandard for many years. When the government proposed to move its offices from Somerset House in the 1830s it was suggested that the hospital should move into the building in conjunction with King’s College. The medical staff themselves wrote to the governors in 1832 suggesting that the hospital should be rebuilt ‘in a more eligible situation’ to promote the benevolent views of the founder and the supporters. The staff pointed to the ‘decayed state of the existing hospital, the great improvements in hospital design, the growth of London which required a more equitable distribution of hospitals, the increased accommodation at Guy’s, and the notoriously smaller number and less urgent importance of cases applying for admission now than formerly.’²The development of the Greenwich Railway from 1837 onwards posed a more direct threat to the hospital’s site, and the problem became acute in 1859 for the rails were going to cut across it passing fifteen feet above ground level within a yard or two of the wards. The disputes which followed brought problems facing the hospitals to public attention. A threat concentrates the mind and many beliefs were re-examined: the sanitary and professional arguments for the town or country location of hospitals; geographical distribution within London; the objectives of the medical charities; and the influence doctors should have on the hospitals’ governors.

When it became clear that the extension of the railway might force St Thomas’s to move, an influential group which included the treasurer and many of the governors favoured relocation in an accessible London suburb to the east. There might be an experiment ‘collecting the sick at a receiving house and sending them for treatment as soon as they could be moved into the pure air of the country’.³The resident medical officer, Mr R G Whitfield, the third of his family to hold this post, favoured this course of action. He believed that the new forms of transport and the changes in the distribution of the population could not be ignored. The population of Greenwich and Lewisham was increasing more than any district south of the Thames, whilst in some parishes in Southwark the population was falling. He argued that the locale of the poor would alter and they must emigrate from necessity, just as the rich had done from choice. He thought that parents would sooner send their sons to a medical school in a neighbourhood more savoury than Southwark and that as most medical treatment was carried out by resident staff a short train journey for visiting staff would prove no hardship.

Whitfield had two campaigns to fight, first to ensure the sale of the whole site, so that the hospital obtained the maximum compensation from the railway company, and secondly to achieve relocation outside London in the country. Distrustful of the motives of the visiting staff, he was at times in almost daily communication with Miss Nightingale, who had a freedom of action which he did not enjoy. Miss Nightingale wrote to him that there was an opportunity to build the finest hospital in the world, but that if St Thomas’s stayed in Southwark it could be no fit place for training nurses. Whitfield replied that he wished he could whisper in Prince Albert’s ear that the prince should interest himself in the debate, and its sanitary importance.⁴Shortly after, in March 1859, the prince spoke to the treasurer on the subject, and he wrote formally to the governors. Whitfield obtained the admission tickets of accident cases from the steward, analysed the patients’ addresses showing that many came from places some way to the south-east, like New Cross, and provided Miss Nightingale with the figures. A few days later the analysis appeared in The Builder, a journal on cordial terms with Miss Nightingale, to support the case for removal to the east. The analysis, when repeated 120 years later, shows how little change has taken place in the origin of patients seen in St Thomas Street, Southwark.

In July 1859 Whitfield took a convalescent holiday in Paris and wrote copious reports to Miss Nightingale about the ventilation and sanitation of the hospitals at Lariboisière and Vincennes.⁴Florence Nightingale opposed the construction of hospitals in towns on sanitary grounds and believed that while special wards might be needed centrally for accident cases and sudden illness, patients should be sent on to suburban hospitals as soon as they were fit to make the journey. A wider distribution would not only make hospitals healthier, but would improve their accessibility to patients.⁵The medical press took different sides in the dispute. The Lancet favoured central location, whilst the Medical Times and Gazette believed that the benefits of removing St Thomas’s from the Borough to a healthy situation in the country, with its pure and invigorating air, would outweigh the inconveniences.

The medical staff at St Thomas’ did not share Whitfield’s views. The governors were bombarded with printed leaflets for the best part of a year. After discussion with Miss Nightingale, Whitfield organised a survey of patients which showed that more came from the south-east than from the ‘home district’ or from the south-west. The south-west seemed a poor place to be in any case, for ‘numerous unhealthy factories saturated the atmosphere with their noxious products making the place perfectly unsuitable for a hospital’. Each governor received an attractively coloured map of South London and statistics of patient flow purporting to show that the main catchment of St Thomas’s was to the south-east. They were presented in a way designed to lead to the conclusion Mr Whitfield favoured.⁸

John Simon and the medical staff remained opposed to a move and Whitfield was forced onto the defensive, saying that he was convinced that ‘by the close of the present century succeeding generations would do full justice to his opinions’.⁹A decision was delayed until the last moment and when the purchase price of the site had been settled by arbitration at £296,000, the hospital had to find a new home as a matter of urgency. Many possibilities were examined, some of which were unsuitably sited near factories and knackers’ yards. Ultimately the governors took a lease on the old Surrey Music Hall in Surrey Gardens, off the Walworth Road immediately to the south of the Elephant and Castle. The old buildings were rapidly converted and this, like the removal, went smoothly. The capacity of St Thomas’s in its new and temporary home was greatly reduced; the buildings themselves were excellent and stood in pleasant grounds. The hospital reopened within weeks and the wards filled rapidly, confirming in the minds of many the need for a central site. Guy’s, now standing alone, came under heavy pressure.

The immediate problem had been solved but there remained a division of opinion about the ideal permanent site. The governors continued to favour relocation in the country, perhaps in Lewisham, whilst the medical staff wished to stay in London. The City of London and the local vestries were alarmed at the prospect of losing the hospital and organised a campaign to keep St Thomas’s in Southwark. The Social Science Association listened to an address in which an idyllic picture was painted of hospitals pleasantly located amidst herds of cows on the southern slopes of the Surrey hills.¹¹The doctors pointed to the need for the hospital to be accessible to sick and injured people, rather than cows. In their view a country site would turn the institution into a convalescent home and undermine the medical school. The staff maintained that the death rate in a hospital had little to do with the type of air it might enjoy. Country air did not of itself reduce mortality for the cause of hospital sepsis lay in the organisation of the hospital itself, not in its surroundings. In a ‘memorial’ addressed to the president, treasurer and governors of the hospital, the medical staff drew attention to the damage which would be inflicted on the hospital and medical school ‘if the new hospital were to be planted in any locality where physicians and surgeons of high metropolitan standing could not be expected to serve it with assiduous attention,'¹²

Throughout 1862 The Lancet ran a campaign against a country site, pouring scorn on the ‘outdated sanitary ideas of the governors' and comparing the results of English and French hospitals. Dr Bristowe, a physician at St Thomas’s, repeated the arguments in favour of a central London location when he gave the opening address of the academic year in the presence of the treasurer, and appealed for improved communications between the governors and the medical staff.¹³Indeed, whilst it was quite true that the suburbs were expanding rapidly, the central boroughs south of the river were themselves desperately in need of hospital accommodation.

The governors gave in to the pressure to remain in central London. Seven sites were short-listed, one of which was the nearby Bethlem Royal Hospital which some believed should be moved into the country in the interests of the long-term residents. Surrey Gardens itself was in many ways ideal, not least because of its size and the wish of the owner to sell to St Thomas’s. Instead the governors chose the Stangate site, part of which was to be reclaimed from the Thames as the Board of Works constructed the embankment. The Lancet was not entirely happy - it seldom was - for as a riverside site it suffered from the stench of the Thames and it was not the healthiest of places. When The Lancet introduced its sanitary report on the Thames it said ‘We have a certain feeling of satisfaction that the Chancellor of the Exchequer, Mr Gladstone, has been forced to beat an ignominious retreat from the Committee Room, handkerchief to nose.’ Worst of all, the Stangate site was costly and required special foundation work. Miss Nightingale also disapproved. She wrote that the position at Westminster Bridge was ‘the worst about London, only 2 feet above the water mark’. It was ‘a place totally unfit for the sick’.¹⁵

Opposition to the Stangate site only ceased after a court case brought by the City of London in March 1864. The governors presented evidence on the healthiness of a riverside location based upon the experience of the Seamen’s Hospital, the Millbank penitentiary and the Hotel Dieu on the banks of the Seine. The court concluded that it had no reason to disturb the deliberate choice of the governors, even though Surrey Gardens was nearer to the original site of the hospital as well as being cheaper.

The governors had been to France to see Lariboisière and Florence Nightingale had been consulted about the plans. Henry Currey’s pavilion plan was settled upon and details published in The Builder and in the medical press. On 13 May 1868, with the solemnity of prayers and psalms, the clang of martial music and the roar of cannon in salutation, the Queen laid the foundation stone. The medical staff looked forward with pleasure to the great new hospital. By current standards it was vast but a system of electric communication was installed ‘to diffuse intelligence’. Some accused the governors of over-lavish expenditure¹⁶, but in general comments were favourable and Queen Victoria returned to open the hospital in 1871. The new St Thomas’s was described by the illustrated London News: ‘The range of buildings has a frontage of 1700 feet, nearly equal to the length of the Crystal Palace. The style of the architecture is Palladian, with rich facings of coloured brick and Portland stone, with carved ballustrades for the balconies.’¹⁷The clinical accommodation provided everything necessary for the work of a great hospital. But the cost had been enormous and the building committee reported on it to the court of the governors. Neither, in spite of all the advice that had been taken, was the hospital free from the infections which its advanced sanitary design was meant to obviate. There was still much to be learned about hospital construction, hospital management and the need for fastidious cleanliness, commented The Lancet.¹⁸There was a risk that the new hospital might be regarded as a model which could be copied with confidence.

There had been no choice for St Thomas’s, but less dramatic measures were open to other hospitals which were also in need of improvement. The Lancet believed that the alterations which had been made to St George’s, Charing Cross and St Mary’s merely proved that money spent on ‘tinkering with old buildings’ instead of partial reconstruction was money wasted. The old hospitals could not be made hygienically perfect and rebuilding on a ‘scientific plan’ would have been preferable.

The Westminster Hospital, although it had been built only forty years before, was in need of upgrading for sanitary reasons by 1877. The estimated cost £13,000 and an alternative proposal to move the hospital to Pimlico, Chelsea, Battersea or Wandsworth appeared in the newspapers. The Lancet considered the matter from the point of view of the needs of the population and examined the bed-ratios on the basis of the 1871 census. Bearing in mind the differing levels of poverty in the various areas, The Lancet did not see that a case had been established for the removal of the Westminster Hospital. Neither did the house committee of the hospital nor its chairman, Sir Rutherford Alcock. The hospital proceeded to carry out the necessary alterations, closing completely for three months. The Lancet, however, urged the governors to try to erect a new building in future which more nearly approached sanitary perfection.¹⁹

Advances in hospital care

There were vast improvements in patient care between 1860 and 1890. Hospitals which had been ‘places which healthy people should avoid and sick people should shun' ²⁰, became the best places for sick men and women to be. Ether had been introduced into the London hospitals in the first quarter of 1847. Antiseptic methods were introduced more gradually between 1870 and 1880, so gradually in fact that The Lancet: in 1875 could still question whether the improved results being obtained were due to better sanitation or Listerian methods.²¹As a result of specialisation and the introduction of laboratory methods doctors could achieve far more. Lastly, there was the great improvement in nursing.

Nursing

In no department of hospital management, said The Lancet in 1864, had there been greater improvements than in nursing.²²Steele, the medical superintendent at Guy’s, thought that the change began around 1850.23 New techniques in medical practice made greater demands upon those caring for patients and ‘it was properly maintained that in every hospital the best possible system of nursing that could be devised should exist, since it was second, and second only, to having the best medical skill’. A nurse now had to be technically trained to assist doctors and, simultaneously, to perform her duties with tenderness, sympathy and kindness — for which it was necessary to raise her social and moral character.²²

There were never enough nurses. To attract staff of a suitable calibre was a constant problem and Dr Elizabeth Garrett told the Social Science Association that hospitals should pay better wages and not rely on religious dedication.²⁴Florence Nightingale disagreed, for she believed that one did not necessarily obtain a better article merely by paying a higher price.²⁵Nevertheless the shortage of applicants forced hospital governors to improve conditions, employ ward-maids and scrubbers and provide better accommodation. One way to improve standards, which was widely adopted, was to appoint more ladies — or at least women with superior education - to act as ward sisters. Ladies could maintain discipline more easily, and with less show of force, but caused expenses to rise.²⁶Lady-sisters wanted more staff, their standards of cleanliness were higher, the wards were more frequently scrubbed and the costs for washing increased. Food costs were also higher, for ‘the sisters would suggest delicacies to those with poor appetites, until patients suffered dyspepsia from over-eating.’ Nevertheless, the British Medical Journal thought that while it was always difficult to combine cheapness with efficiency, lady-sisters were the basis of the best system of nursing yet introduced.

In an attempt to improve standards, parties of governors visited each other’s hospitals. In 1864 a group from the Norfolk and Norwich Hospital visited St Thomas’s, King’s College Hospital, University College Hospital and St Bartholomew’s. They wished to transfer the better features of nursing in London to their own hospital and Mr Whitfield provided them with the instructions issued to the probationers at St Thomas’s.²⁷

The Middlesex Hospital reviewed its nursing in 1864-5. The doctors suggested that Miss Twining might introduce the probationers of her institution, St Luke’s, but the governors, having visited other hospitals, proposed instead to appoint a lady-superintendent, build a nurses’ home, introduce a uniform, institute nurse training and make other arrangements for the menial duties to be performed. At the Westminster Hospital a committee chaired by Sir Rutherford Alcock was established in 1872 to assess the alternative systems of providing nurses and to improve the standard of the hospital’s nursing. It reported that no amount of medical skill or expenditure of money was effective in treating and curing the sick if good nursing was wanting. Without intelligent training under superior guidance good nursing could not be expected. The idea of employing a sisterhood was rejected and, liking the results produced by the Liverpool Royal Infirmary training school, Miss Elizabeth Merryweather was invited south to become matron in 1873.²⁸

Steele, of Guy’s, believed that every major hospital would benefit from having its own training institution.²⁸The Nightingale Fund, though first in the field, did not escape criticism. ‘With all these efforts to provide additional trained nurses’, said The Lancet, ‘one cannot help asking “what is done with the Nightingale Fund?” It was supposed to be devoted to training hospital nurses for all our public hospitals ... We must confess to have never come across a specimen of a Nightingale nurse except in the wards of St Thomas’s.’²⁹By the early 1870s almost all the great London hospitals, with the exception of St Mary’s, professed to train young women as nurses.³⁰Yet a survey carried out in 1875 by a Nightingale nurse, Florence Lees, showed that in most of them probationers were merely placed in the wards to pick up what knowledge they could. Only at the Middlesex, the Westminster, the Royal Free and St Thomas’s was some attempt made to provide systematic training. St Thomas’s training programme was adopted by some other hospitals - like the Middlesex - but the Nightingale School was not the only pace-setter. St Bartholomew’s established its new school in 1877 and appointed a physician and surgeon as instructors, so the teaching could be both practical and systematic. Sir Dyce Duckworth, who took a particular interest in the school, delivered the inaugural lecture on ‘Sick Nursing, a Woman’s Mission’. He exhorted the nurses to be obedient, observant, cheerful and clean in their work. He did not urge total abstention on them, but suggested that nurses only drank with their meals.³¹

The Lancet described the two plans which had been introduced into London hospitals. One was training by sisterhoods or religious orders, as in Catholic countries on the continent and at the Protestant Kaiserswerth. By 1864 twenty six sisterhoods of this type had been established in England, one of the largest being St John’s House which provided the nursing at King’s College Hospital at a cost of £1,000 per year, and at Charing Cross. Another order, All Saints, nursed at University College Hospital. One hospital, the Prince of Wales at Tottenham, actually developed out of a Deaconesses Training Institution, established in 1868 in the Kaiserswerth tradition. Here evangelical dedication and low pay was found at its most extreme. The other approach, which The Lancet favoured, was the one in vogue at St Thomas’s, where the Nightingale Fund, which had been collected at the end of the Crimean war, had been used to establish a training school. The object of this fund was to train women thoroughly for all the practical duties of hospital nursing, to find them situations and to train those who would in future train others.²²

The Nightingale School, which admitted its first probationers in 1860, had no easy time. King’s College Hospital, the London and the Royal Free were considered as a base, but the Nightingale Fund Committee eventually selected St Thomas’s for the quality of its nursing and its matron, Mrs Wardroper. Writing after her death, Florence Nightingale said that Mrs Wardroper weeded out the inefficient, morally and technically, and put her finger on some of the most flagrant blots, like night nursing. During Mrs Wardroper’s lifetime Miss Nightingale was not always so complimentary and detailed studies of the school’s history have shown that in terms of discipline and educational matters often left much to be desired. There was no immediate revolutionary improvement on the wards. For many years the school’s probationers represented only a small proportion of the hospital’s nursing staff.

The best nurses, in Mrs Wardroper’s opinion, were to be obtained from amongst women of the respectable classes, who had had the benefit of a fair education, and who had been accustomed to the performance of household duties. In the search for ‘raw material’ one should go neither too high nor too low in the scale or one would be disappointed. Such ladies as possessed the gift of organisation and arrangement would prove valuable assistants as superintendents, sisters or head nurses, but to be of real use as nurses in the sick wards ladies too must qualify for the work by training for it.

While the sisterhoods were necessarily restricted to one form of religious persuasion in the selection of their probationers, this sectarian exclusiveness was not allowed at the Nightingale School. Technical instruction and proper supervision was the objective. Ward teaching was considered crucial, for Miss Nightingale believed that surgical nursing could only be learned thoroughly in the wards, and that the perfection of nursing might be seen practised by the old-fashioned sister of the London hospitals.³³The Nightingale School always wanted their probationers to be considered in some senses supernumerary, so that there was time to absorb the teaching. Ward teaching was supplemented by theoretical instruction from the resident medical officer, Mr Whitfield, although he did not lecture to the nurses as often as he was supposed to. Simultaneously the probationer’s social and moral character was uplifted, at least in theory, by living in the nurses’ home.

A revolutionary feature of Florence Nightingale’s plan for nurse training was the demand that the entire control of the nursing staff should be taken out of the hands of men, whether doctors, governors or chaplains, and placed in the charge of a woman, herself a trained and competent nurse. Hospital governors did not always accept the necessity for this. Female control was more important to Miss Nightingale than whether nursing was secular or controlled by a sisterhood. From Notes on Hospitals it is clear that she approved of religious nursing orders with their female heads.³⁴In most hospitals the nurses were controlled as to discipline, education and work by the hospital managers and the medical staff; to change this was Miss Nightingale’s fundamental aim.